MEDICARE: WENDY PORTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	118793	MA

General Provider Information

NPI Number	:	1588143879
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	WENDY PORTER

Provider Business Mailing Address
First Line	:	61 INDUSTRIAL PARK RD
Second Line	:
City	:	PLYMOUTH
State	:	MA
Zip	:	02360-7246
Country	:	US
Telephone Number	:	508-732-6331
Fax Number	:	508-747-1239

Provider Business Practice Location Address
First Line	:	61 INDUSTRIAL PARK RD
Second Line	:
City	:	PLYMOUTH
State	:	MA
Zip	:	02360-7246
Country	:	US
Telephone Number	:	508-732-6331
Fax Number	:	508-747-1239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/08/2018
Last Update Date	:	08/08/2018

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Directions to “ WENDY PORTER ” Practice Location

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